Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.
ABSTRACT Guidelines for the management of patients with invasive candidiasis and mucosal candidiasis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous guidelines published in the 15 January 2004 issue of Clinical Infectious Diseases and are intended for use by health care providers who care for patients who either have or are at risk of these infections. Since 2004, several new antifungal agents have become available, and several new studies have been published relating to the treatment of candidemia, other forms of invasive candidiasis, and mucosal disease, including oropharyngeal and esophageal candidiasis. There are also recent prospective data on the prevention of invasive candidiasis in high-risk neonates and adults and on the empiric treatment of suspected invasive candidiasis in adults. This new information is incorporated into this revised document.
- SourceAvailable from: oxfordjournals.org[show abstract] [hide abstract]
ABSTRACT: In order to determine the current prevalence and incidence of fluconazole-resistant oropharyngeal candidiasis among human immunodeficiency virus (HIV)-infected patients, we conducted a prospective observational study of a consecutive series of HIV-infected patients. Of 128 enrolled patients, 70 patients completed four quarterly follow-up visits over a period of 1 year. Over this period, declining rates of carriage of Candida albicans (from 61% to 39%; P = .008) and of oropharyngeal candidiasis (from 30% to 4%; P < .001) were documented. Trends toward reduction in the frequency of fluconazole-resistant isolates (MIC, > or = 64 micrograms/mL) were also seen. During the survey period, the mean (median) number of antiretroviral agents used per patient rose from 0.5 (0) to 1.8 (2) (P < .001). Thus, rather than progression, we observed declining rates of oropharyngeal candidiasis, C. albicans carriage, and fluconazole-resistant C. albicans in a cohort of HIV-infected patients treated with increasingly effective antiretroviral therapy.Clinical Infectious Diseases 12/1998; 27(5):1291-4. · 9.37 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Fungal mural endocarditis is a rare entity in which the antemortem diagnosis is seldom made. Seven cases of mural endocarditis caused by Candida spp. have been collected from literature and six of these patients died after treatment with amphotericin B. We report a case of mural endocarditis diagnosed by transesophageal echocardiogram and positive blood cultures to Candida parapsilosis. Because blood cultures continued to yield C. parapsilosis despite caspofungin monotherapy, treatment with voriconazole was added. This is the first description of successful treatment of C. parapsilosis mural endocarditis with caspofungin and voriconazole.BMC Infectious Diseases 02/2006; 6:73. · 3.03 Impact Factor
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ABSTRACT: The presence of Candida species in the urine is frequent among hospitalized patients. We studied sample urine of 205 hospitalized patients during a 1-year period to determine the incidence of nosocomial candiduria. The yeasts were isolated in 22% (45/205) urine cultures and risk factors in these patients were analyzed. Candida albicans was isolated in 35.6% and C. tropicalis (22%) was the second most frequent species isolated. Most patients were women (57.8%) with a mean age of 48.7 years. The principal risk factors that were observed in patients with candiduria included antibiotics therapy (100%), urinary catheterization (84.4%), surgical procedure (66.7%), female sex and extended hospitalization. The efficacy of fluconazole therapy to eradicate Candida from urine was demonstrated (p =0.05). Of the 23 individuals who received antifungal therapy, candiduria persisted in 9 (39.2%) and of 22 patients who received no antifungal therapy, the candiduria persisted in 15 (68.2%).Mycopathologia 08/2004; 158(1):49-52. · 1.49 Impact Factor
Treatment Guidelines for Candidiasis • CID 2009:48 (1 March) • 503
I D S A G U I D E L I N E S
Clinical Practice Guidelines for the Management
of Candidiasis: 2009 Update by the Infectious
Diseases Society of America
Peter G. Pappas,1Carol A. Kauffman,2David Andes,4Daniel K. Benjamin, Jr.,5Thierry F. Calandra,11
John E. Edwards, Jr.,6Scott G. Filler,6John F. Fisher,7Bart-Jan Kullberg,12Luis Ostrosky-Zeichner,8
Annette C. Reboli,9John H. Rex,13Thomas J. Walsh,10and Jack D. Sobel3
1University of Alabama at Birmingham, Birmingham;
Vaudois, Lausanne, Switzerland;
Pharmaceuticals, Manchester, United Kingdom
2University of Michigan and Ann Arbor Veterans Administration Health Care System, Ann
3Wayne State University, Detroit, Michigan;
6Harbor–University of California at Los Angeles Medical Center, Torrance;
9Cooper Hospital, Camden, New Jersey;
12Nijmegen University Centre for Infectious Diseases, Nijmegen, The Netherlands; and
4University of Wisconsin, Madison;
5Duke University Medical Center, Durham, North
7Medical College of Georgia, Augusta;
10National Cancer Institute, Bethesda, Maryland;
8University of Texas at
11Centre Hospitalier Universitaire
Guidelines for the management of patients with invasive candidiasis and mucosal candidiasis were prepared
by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replacetheprevious
guidelines published in the 15 January 2004 issue of Clinical Infectious Diseases and are intended for use by
health care providers who care for patients who either have or are at risk of these infections. Since 2004,
several new antifungal agents have become available, and several new studies have been published relating to
the treatment of candidemia, other forms of invasive candidiasis, andmucosaldisease,includingoropharyngeal
and esophageal candidiasis. There are also recent prospective data on the prevention of invasive candidiasis
in high-risk neonates and adults and on the empiric treatment of suspected invasive candidiasis in adults.
This new information is incorporated into this revised document.
There have been several significant changes in the man-
agement of candidiasis since the last publication of
these guidelines in January 2004. Most of these changes
relate to the appropriate use of echinocandins and ex-
panded spectrum azoles in the management of can-
didemia, other forms of invasive candidiasis, and mu-
cosal candidiasis. For some of the less common forms
of invasive candidiasis (e.g., chronic disseminated can-
didiasis, osteomyelitis, and CNS disease), there are few
new treatment data since 2004, with only anecdotal
Received 21 November 2008; accepted 24 November 2008; electronically
published 29 January 2009.
These guidelines were developed and issued on behalf of the Infectious
Diseases Society of America.
Reprints or correspondence: Dr. Peter G. Pappas, Dept. of Medicine, Div. of
Infectious Diseases, University of Alabama at Birmingham, 1900 University Blvd,
THT 229, Birmingham, Alabama 35294-0006 (email@example.com).
Clinical Infectious Diseases2009;48:503–35
? 2009 by the Infectious Diseases Society of America. All rights reserved.
experience, case reports, or small series providing some
evidence to support new approaches to therapy. Each
section of the Guideline begins with a specific clinical
question and is followed by numbered recommenda-
tions and a summary of the most-relevant evidence in
support of the recommendations. The most significant
changes and/or additions to existing recommendations
are described below in the Executive Summary. The
remaining topics are discussed in greater detail in the
main body of the guidelines.
Candidemia in Nonneutropenic Patients
•Fluconazole (loading dose of 800 mg [12 mg/kg],
then 400 mg [6 mg/kg] daily) or an echinocandin
(caspofungin: loading dose of 70 mg, then 50 mg
daily; micafungin: 100 mg daily; anidulafungin: load-
ing dose of 200 mg, then 100 mg daily) is recom-
mended as initial therapy for most adult patients (A-
I). The Expert Panel favors an echinocandin for
patients with moderately severe to severe illness or
504 • CID 2009:48 (1 March) • Pappas et al.
for patients who have had recent azole exposure (A-III). Flu-
conazole is recommended for patients who are less critically
ill and who have had no recent azole exposure (A-III). The
same therapeutic approach is advised for children, with at-
tention to differences in dosing regimens.
•Transition from an echinocandin to fluconazole is recom-
mended for patients who have isolates that are likely to be
susceptible to fluconazole (e.g.,Candida albicans) and who
are clinically stable (A-II).
•For infection due to Candida glabrata, an echinocandin is
preferred (B-III). Transition to fluconazole or voriconazole
therapy is not recommended without confirmation of isolate
susceptibility (B-III). For patients who have initially received
fluconazole or voriconazole, are clinically improved, and
whose follow-up culture results are negative, continuing use
of an azole to completion of therapy is reasonable (B-III).
•For infection due to Candida parapsilosis, treatment with
fluconazole is recommended (B-III). For patients who have
initially received an echinocandin, are clinically improved,
and whose follow-up culture results are negative, continuing
use of an echinocandin is reasonable (B-III).
•Amphotericin B deoxycholate (AmB-d) administered at a
dosage of 0.5–1.0 mg/kg daily or a lipid formulation of AmB
(LFAmB) administered at a dosage of 3–5 mg/kg daily are
alternatives if there is intolerance to or limited availability of
other antifungals (A-I). Transition from AmB-d or LFAmB
to fluconazole is recommended for patients who have isolates
that are likely to be susceptible to fluconazole (e.g., C. al-
bicans) and who are clinically stable (A-I).
•Voriconazole administered at a dosage of 400 mg (6 mg/kg)
twice daily for 2 doses and then 200 mg (3mg/kg) twice daily
thereafter is effective for candidemia (A-I), but it offers little
advantage over fluconazole and is recommended as step-
down oral therapy for selected cases of candidiasis due to
Candida krusei or voriconazole-susceptible C. glabrata (B-
•The recommended duration of therapy for candidemia with-
out obvious metastatic complications is for 2 weeks after
documented clearance of Candida from the bloodstream and
resolution of symptoms attributable to candidemia (A-III).
•Intravenous catheter removal is strongly recommended for
nonneutropenic patients with candidemia (A-II).
Candidemia in Neutropenic Patients
•An echinocandin (caspofungin: loading dose of 70 mg, then
50 mg daily; micafungin: 100 mg daily [A-II]; anidulafungin:
loading dose of 200 mg, then 100 mg daily [A-III])orLFAmB
(3–5 mg/kg daily [A-II]) is recommended for most patients.
•For patients who are less critically ill and who have no recent
azole exposure, fluconazole (loading dose of 800 mg [12 mg/
kg], then 400 mg [6 mg/kg] daily) is a reasonable alternative
(B-III). Voriconazole can be used in situations in which ad-
ditional mold coverage is desired (B-III).
•For infections due to C. glabrata,anechinocandinispreferred
(B-III). LFAmB is an effective but less attractive alternative
(B-III). For patients who were already receiving voriconazole
or fluconazole, are clinically improved, and whose follow-up
culture results are negative, continuing use of the azole to
completion of therapy is reasonable (B-III).
•For infections due to C. parapsilosis, fluconazole or LFAmB
is preferred as initial therapy (B-III). If the patientisreceiving
an echinocandin, is clinically stable, and follow-up culture
results are negative, continuing the echinocandin until com-
pletion of therapy is reasonable. For infections due to C.
krusei, an echinocandin, LFAmB, or voriconazole is recom-
•Recommended duration of therapy for candidemia without
persistent fungemia or metastaticcomplicationsisfor2weeks
after documented clearance of Candida from the blood-
stream, resolution of symptoms attributable to candidemia,
and resolution of neutropenia (A-III).
•Intravenous catheter removal should be considered (B-III).
Empirical Treatment for Suspected Invasive Candidiasis in
•Empirical therapy for suspected candidiasis in nonneutro-
penic patients is similar to that for proven candidiasis. Flu-
conazole (loading dose of 800 mg [12mg/kg], then 400 mg
[6 mg/kg] daily), caspofungin (loading dose of 70 mg, then
50 mg daily), anidulafungin (loading dose of 200 mg, then
100 mg daily), or micafungin (100 mg daily) isrecommended
as initial therapy (B-III). An echinocandin is preferred for
patients who have had recent azole exposure, whose illness
is moderately severe or severe, or who are at high risk of
infection due to C. glabrata or C. krusei (B-III).
•AmB-d (0.5–1.0 mg/kg daily) or LFAmB (3–5 mg/kg daily)
are alternatives if there is intolerance to other antifungals or
limited availability of other antifungals (B-III).
•Empirical antifungal therapy should be considered for crit-
ically ill patients with risk factors for invasive candidiasis and
no other known cause of fever, and it should be based on
clinical assessment of risk factors, serologic markers for in-
vasive candidiasis, and/or culture data from nonsterile sites
Empirical Treatment for Suspected Invasive Candidiasis in
•LFAmB (3–5 mg/kg daily), caspofungin (loading dose of 70
mg, then 50 mg daily) (A-I), or voriconazole (6 mg/kg ad-
ministered intravenously twice daily for 2 doses, then 3 mg/
kg twice daily) are recommended (B-I).
•Fluconazole (loading dose of 800 mg [12 mg/kg], then 400
mg [6 mg/kg] daily) and itraconazole(200mg[3mg/kg]twice
daily) are alternative agents (B-I).
•AmB-d is an effective alternative, but there is a higher risk
Treatment Guidelines for Candidiasis • CID 2009:48 (1 March) • 505
of toxicity with this formulation than with LFAmB (A-I).
•Azoles should not be used for empirical therapy in patients
who have received an azole for prophylaxis (B-II).
Treatment for Neonatal Candidiasis
•AmB-d (1 mg/kg daily) is recommended for neonates with
disseminated candidiasis (A-II). If urinary tract involvement
is excluded, LFAmB (3–5 mg/kg daily) can be used (B-II).
Fluconazole (12 mg/kg daily) is a reasonable alternative (B-
II). The recommended length of therapy is 3 weeks (B-II).
•A lumbar puncture and a dilated retinal examination, pref-
erably by an ophthalmologist, are recommended in neonates
with sterile body fluid and/or urine cultures positive for Can-
dida species (B-III). Imaging of the genitourinary tract, liver,
and spleen should be performed if the results of sterile body
fluid cultures are persistently positive (B-III).
•Echinocandins should be used with caution and are generally
limited to situations in which resistance or toxicity precludes
the use of fluconazole or AmB-d (B-III).
•Intravascular catheter removal is strongly recommended (A-
•In nurseries with high rates of invasive candidiasis, flucon-
azole prophylaxis may be considered in neonates whose birth
weight is !1000 g (A-I). Antifungal drug resistance, drug-
related toxicity, and neurodevelopmental outcomes should
be observed (A-III).
Antifungal Prophylaxis for Solid-Organ Transplant Recipients,
Patients Hospitalized in Intensive Care Units (ICUs),
Neutropenic Patients receiving Chemotherapy, and Stem Cell
Transplant Recipients at Risk of Candidiasis
•For solid-organ transplant recipients, fluconazole (200–400
mg [3–6 mg/kg] daily) or liposomal AmB (L-AmB) (1–2 mg/
kg daily for 7–14 days) is recommended as postoperative
antifungal prophylaxis for liver (A-I), pancreas (B-II), and
small bowel (B-III) transplant recipients at high risk of
•For patients hospitalized in the ICU, fluconazole (400 mg [6
mg/kg] daily) is recommended for high-risk patients in adult
units that have a high incidence of invasive candidiasis (B-
•For patients with chemotherapy-induced neutropenia, flu-
conazole (400 mg [6 mg/kg} daily) (A-I), posaconazole (200
mg 3 times daily) (A-I), or caspofungin (50 mg daily) (B-
II) is recommended during induction chemotherapy for the
duration of neutropenia. Oral itraconazole (200 mg twice
daily) is an effective alternative (A-1), but it offers little ad-
vantage over other agents and is less well tolerated.
•For stem cell transplant recipients with neutropenia, flucon-
azole (400 mg [6 mg/kg] daily), posaconazole (200 mg 3
times daily), or micafungin (50 mg daily) is recommended
during the period of risk of neutropenia (A-I).
Candida species are the most common cause of invasive fungal
infections in humans, producing infections that range from
non–life-threatening mucocutaneous disorders to invasive dis-
ease that can involve any organ. Invasive candidiasis is largely
a disease of medical progress, reflecting the tremendous ad-
vances in health care technology over the past several decades
[1–5]. The most frequently implicated risk factors include the
use of broad-spectrum antibacterial agents, use of central ve-
nous catheters, receipt of parenteral nutrition, receipt of renal
replacement therapy by patients in ICUs, neutropenia, use of
implantable prosthetic devices, and receipt of immunosup-
pressive agents (including glucocorticosteroids, chemothera-
peutic agents, and immunomodulators) [2–7]. Candidemia is
the fourth most common cause of nosocomial bloodstream
infections in the United States and in much of the developed
world [5, 8–10]. Invasive candidiasis has a significant impact
on patient outcomes, and it has been estimated that the at-
tributable mortality of invasive candidiasis is as high as 47%
, although many authorities estimate the attributable mor-
tality to be 15%–25% for adults and 10%–15% for neonates
and children [12, 13]. The estimated additional cost of each
episode of invasive candidiasis in hospitalized adults is
∼$40,000 [1, 13].
The Expert Panel addressed the following clinical questions:
I.What is the treatment of candidemia in nonneutropenic
II.What is the treatment of candidemia in neutropenic
III.What is the empirical treatment for suspected invasive
candidiasis in nonneutropenic patients?
IV.What is the empirical treatment for suspected invasive
candidiasis in neutropenic patients?
V.What is the treatment for urinary tract infections due to
VI.What is the treatment for vulvovaginal candidiais?
VII.What is the treatment for chronic disseminated
VIII.What is the treatment for osteoarticular infections due
to Candida species?
IX.What is the treatment for CNS candidiasis in adults?
X.What is the treatment for Candida endophthalmitis?
XI.What is the treatment for infectionsofthecardiovascular
system due to Candida species?
XII.What is the treatment for neonatal candidiasis?
XIII.What is the significance of Candida species isolated
from respiratory secretions?
XIV.What is the treatment for nongenital mucocutaneous
506 • CID 2009:48 (1 March) • Pappas et al.
ranking recommendations in clinical guidelines.
Infectious Diseases Society of America–US Public Health Service Grading System for
Category, grade Definition
Strength of recommendation
Quality of evidence
Good evidence to support a recommendation for or against use
Moderate evidence to support a recommendation for or against use
Poor evidence to support a recommendation
Evidence from ?1 properly randomized, controlled trial
Evidence from ?1 well-designed clinical trial, without randomiza-
tion; from cohort or case-controlled analytic studies (preferably
from 11 center); from multiple time-series; or from dramatic re-
sults from uncontrolled experiments
Evidence from opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert committees
Adapted from Canadian Task Force on the Periodic Health Examination .
transplant recipients, ICU patients, neutropenic patients re-
ceiving chemotherapy, and stem cell transplant recipients at
risk of candidiasis?
Should antifungal prophylaxis be used for solid-organ
Practice guidelines are systematically developed statements to
assist practitioners and patients in making decisions about ap-
propriate health care for specific clinical circumstances .
Attributes of good guidelines include validity, reliability, re-
producibility, clinical applicability, clinical flexibility, clarity,
multidisciplinary process, review of evidence, and documen-
The Infectious Diseases Society of America (IDSA) Standards
and Practice Guidelines Committee (SPGC) convened experts
in the management of patients with candidiasis. The specialties
of the members of the Expert Panel are listed at the end of the
Literature Review and Analysis
For the 2009 update, the Expert Panel completed the review
and analysis of data published since 2004. Computerized lit-
erature searches of the English-language literature using
PubMed were performed.
In evaluating the evidence regarding the management of can-
didiasis, the Expert Panel followed a process used in the de-
velopment of other IDSA guidelines. The process included a
systematic weighting of the quality of the evidence and the
grade of recommendation (table 1) .
Consensus Development on the Basis of Evidence
The Expert Panel met in person on 1 occasion and via tele-
conference 11 times to discuss the questions to be addressed,
to make writing assignments, and to deliberate on the rec-
ommendations. All members of the Expert Panel participated
in the preparation and review of the draft guidelines. Feedback
from external peer reviews was obtained. The guidelines were
reviewed and approved by the IDSA SPGC and the IDSA Board
of Directors prior to dissemination. A summary of the rec-
ommendations is included in table 2.
Guidelines and Conflict of Interest
All members of the Expert Panel complied with theIDSApolicy
on conflicts of interest, which requires disclosure of any finan-
cial or other interest that might be construed as constituting
an actual, potential, or apparent conflict. Members of the
Expert Panel were provided with the IDSA’s conflict of interest
disclosure statement and were asked to identify ties to com-
panies developing products that might be affected by prom-
ulgation of the guidelines. Information was requested regarding
employment, consultancies, stock ownership, honoraria, re-
search funding, experttestimony,andmembershiponcompany
advisory committees. The Expert Panel made decisions on a
case-by-case basis as to whether an individual’s role should be
limited as a result of a conflict. Potential conflicts of interest
are listed in the Acknowledgments section.
At annual intervals, the Expert Panel Chair, the SPGC liaison
advisor, and the Chair of the SPGC will determine the need
for revisions to the guidelines on the basis of an examination
Treatment Guidelines for Candidiasis • CID 2009:48 (1 March) • 507
of current literature. If necessary, the entire Expert Panel will
be reconvened to discuss potential changes. When appropriate,
the Expert Panel will recommend revision of the guidelines to
the SPGC and the IDSA Board for review and approval.
Pharmacologic Considerations of Therapy for Candidiasis
Systemic antifungal agents shown to be effective for the treat-
ment of candidiasis comprise 4 major categories: the polyenes
(AmB-d, L-AmB, AmB lipid complex [ABLC], and AmB col-
loidal dispersion [ABCD]), the triazoles (fluconazole, itracon-
azole, voriconazole, and posaconazole),theechinocandins(cas-
pofungin, anidulafungin, and micafungin), and flucytosine.
Clinicians should become familiar with strategies to optimize
efficacy through an understanding of relevant pharmacokinetic
Amphotericin B (AmB)
Most experience with AmB is with the deoxycholate prepara-
tion (AmB-d). Three LFAmBs have been developed and ap-
proved for use in humans: ABLC, ABCD, and L-AmB. These
agents possess the same spectrum of activity as AmB-d. The 3
LFAmBs have different pharmacological properties and rates
of treatment-related adverse events and should not be inter-
changed without careful consideration. In this document, a
reference to AmB, without a specific dose or other discussion
of form, should be taken to be a reference to the general use
of any of the AmB preparations. For most forms of invasive
candidiasis, the typical intravenous dosage for AmB-d is 0.5–
0.7 mg/kg daily, but dosages as high as 1 mg/kg daily should
be considered for invasive Candida infections caused by less
susceptible species, such as C. glabrata and C. krusei.Thetypical
dosage for LFAmB is 3–5 mg/kg daily when used for invasive
candidiasis [16, 17]. Nephrotoxicity is the most common se-
rious adverse effect associated with AmB-d therapy, resulting
in acute renal failure in up to 50% of recipients . LFAmBs
are considerably more expensive than AmB-d, but all have
considerably less nephrotoxicity [19–21]. These agents retain
the infusion-related toxicities associated with AmB-d. Among
these agents, a comparative study suggests that L-AmB may
afford the greatest renal protection . The impact of the
pharmacokinetics and differences in toxicity of LFAmB has not
been formally examined in clinical trials. We are not aware of
any forms of candidiasis for which LFAmB is superior to AmB-
d, nor are we aware of any situations in which these agents
would be contraindicated, with the exception of urinary tract
candidiasis, in which the protection of the kidney afforded by
the pharmacological properties of these formulations has the
theoretical potential to reduce delivery of AmB . Animal
model studies suggest a pharmacokinetic and therapeutic ad-
vantage for L-AmB in the CNS . Data demonstrating that
AmB-d–induced nephrotoxicity is associated with a 6.6-fold
increase in mortality have led many clinicians to use LFAmB
as initial therapy for individuals who are at high risk of ne-
Fluconazole, itraconazole, voriconazole, and posaconazole
demonstrate similar activity against most Candida species [25,
26]. Each of the azoles has less activity against C. glabrata and
C. krusei. All of the azole antifungals inhibit cytochrome P450
enzymes to some degree. Thus, clinicians must carefully con-
sider the influence on a patient’s drug regimen when adding
or removing an azole. In large clinical trials, fluconazole dem-
onstrated efficacy comparable to that of AmB-d for the treat-
ment of candidemia [27, 28] and is also considered to be stan-
dard therapy for oropharyngeal, esophageal, and vaginal
candidiasis [29, 30]. Fluconazole is readily absorbed, with oral
bioavailability resulting in concentrations equal to ∼90% of
those achieved by intravenous administration. Absorption is
not affected by food consumption, gastric pH, or disease state.
Among the triazoles, fluconazole has the greatest penetration
into the CSF and vitreous body, achieving concentrations of at
least 50% of those in serum ; for this reason, it is used in
the treatment of CNS and intraocular Candida infections. Flu-
conazole achieves urine concentrations that are 10–20 times
the concentrations in serum. For patients with invasive can-
of 800 mg (12 mg/kg), followed by a daily dose of 400 mg (6
mg/kg); a lower dosage is required in patients with creatinine
clearance !50 mL/min.
Itraconazole is generally reserved for patients with mucosal
candidiasis, especially those who have experienced treatment
failure with fluconazole . There are few data that examine
the use of itraconazole in the treatment of invasive candidiasis.
Gastrointestinal absorption differs for the capsule and the oral
solution formulations. Histamine receptorantagonistsandpro-
ton pump inhibitors result in decreased absorption of the cap-
sule formulation, whereas acidic beverages, such as carbonated
drinks and cranberry juice, enhance absorption . Admin-
istration of the capsule formulation with food increases ab-
sorption, but the oral solution is better absorbed on an empty
stomach . Oral formulations are dosed in adults at 200 mg
3 times daily for 3 days, then 200 mg once or twice daily
Voriconazole is effective for both mucosal and invasive can-
didiasis. Its clinical use has been primarily for step-down oral
therapy for patients with infection due to C. krusei and flu-
conazole-resistant, voriconazole-susceptible C. glabrata. CSF
and vitreous penetration is excellent [35, 36]. Voriconazole is
available in both oral and parenteral preparations. The oral
bioavailability of voriconazole is 190% and is not affected by